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changes.mady.by.user Ken Bour

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changes.mady.by.user Terri Agnew

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1) Your Name:

Text Data

name	NAME
width	250px
content	text

Personal Profile Picture/Image (Optional):
(Instructions: Click in the field to the right to open up the text input window. Then click the <Insert> menu button, select <Image>, then choose (or browse) to locate an image file (e.g., JPG, PNG, BMP) from your local computer to upload. After insertion, please click on the picture and adjust the size to no larger than 200 pixels).

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name	IMAGE

2) Stakeholder Group:

List Data

name	SG

1Registries

2Registrars

3Commercial

4Non-Commercial

5Not Applicable

3) Constituency:

List Data

name	CONSTITUENCY

1Business (BC)

2Intellectual Property (IPC)

3Internet Service Providers (ISPC)

4Non-Commercial Users (NCUC)

5Not-for-Profit Operational Concerns (NPOC)

6Not Applicable

4) ICANN Affiliation (if not covered by item 2 or 3):

Text Data

name	AFFIL
width	250px
content	text

5) Please identify your current employer(s):

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name	EMPLOYER
width	250px
content	text

6) Please identify your current position(s):

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name	POSITION
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content	text

7) Please identify the type(s) of work performed:

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name	WORK
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content	text

8) Please identify your declared country of primary residence (e.g., country to which you pay taxes):

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name	COUNTRY
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content	text

9) Please list any financial relationship beyond de minimusminimis stock ownership you may have with any company that to your knowledge has a financial relationship or contract with ICANN:

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name	RELATIONSHIP
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content	text

10) Do you believe you are participating in the GNSO policy process as a representative of any individual or entity, whether paid or unpaid?

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Yes

If the answer is “Yes,” please provide the name of the represented individual or entity. (If professional ethical obligations prevent you from disclosing this information, please enter "Private"):

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width	250px
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11) Please identify any other relevant arrangements, interests, or benefits as requested in the following two questions:

a) Do you have any type of material interest in ICANN GNSO policy development processes and outcomes?

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name	INTEREST
separator	newline

Yes

If the answer is “yes,” please describe the material interest in ICANN GNSO policy development processes and outcomes:

Text Data

name	INTERESTEXPLAIN
width	250px
content	text

b) Are there any arrangements/agreements between you and any other group, constituency or person(s) regarding your participation as a work team member?

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Yes

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name	ARRANGEEXPLAIN
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12) Please identify any Working Groups or other chartered teams in which you are participating (include acronyms, if applicable):

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